How does accountability to patients and the public fit into the commissioning framework, asks David Colin-Thome. Below, Tim Gilling outlines the 10 areas essential to effective scrutiny

Having spent 11 years as a district councillor, I welcome the idea that local government should call health services more closely to account on health and well-being - not least because of local government's huge influence on public health.

I am also completely convinced of the need for wider patient and public influence in the design and delivery of services. The big question is: how can local authority overview and scrutiny committees and the new local involvement networks (LINks) bring their influence to bear on an NHS driven by commissioning and patient choice?

A recent House of Commons seminar, hosted by the Centre for Public Scrutiny, discussed a four-stage iterative commissioning cycle, to which I have added an additional first stage, at each point of which patient and public involvement is needed:

  • definition of need of population for which commissioning is to be done;
  • commissioning strategy and decisions;
  • scrutiny of commissioning;
  • implementation of commissioning;
  • commissioning outcomes through service provision.

This provides a useful framework within which to consider how the commissioning cycle can be held to account. Commissioning is perhaps the more difficult of the commissioner/provider split when it comes to accountability. It raises complex questions, which were deliberated at our seminar.

One of the strongest policy drivers for reinforcing the role of commissioning is to change the direction of health services - to rethink the settings in which they are delivered - to make them more responsive to service users' needs and preferences and to pay more attention to the 'Cinderella services', like long-term care and mental health. A big challenge for patient and public involvement and scrutiny is to look at commissioning from this perspective. What are the accountability mechanisms that can be used to measure how well the commissioning process is meeting these objectives and, in particular, transforming the Cinderella services?

Multi-level process

Commissioning is a multi-level process: it takes place at the individual level, the practice or institutional level and the strategic level. All these levels need to be informed by each other with
patient and public involvement
all the way up the line.

There is a huge education agenda here. The new LINks will want to go and find out what services users and carers think about services. How will they add value to all the other forms of engagement going on in the NHS and will they have the opportunity to engage at the strategic level of commissioning? This is unlikely, without greater mutual understanding and education of commissioners and the public.

Similarly, GPs and other 'new' commissioners will need help in understanding the role and processes of public scrutiny. (By the way, I would argue that as a GP I've been commissioning for 36 years - they used to call it referrals!)

It can be a daunting prospect to be invited to 'give evidence' in public to a local OSC. But OSCs will surely want to hear from GP commissioners from time to time - and rightly so, given their extended budgets.

At the same time, we are expecting more and more commissioning of providers outside the NHS to take place. And we may also see contracting out of aspects of commissioning itself. Voluntary sector organisations, which may increasingly become NHS providers, are used to public scrutiny of their activities. But we will need to ensure public accountability for contracts that have traditionally been subject to 'commercial confidentiality' claims and for organisations that have not worked within a democratic framework. This will be a huge challenge, requiring understanding and commitment
on all sides.

With the perpetual and necessary revolution taking place within the NHS to meet the changing aspirations of patients and public, and the frequent changes of elected council members, there will be a continuing need for mutual education and support for scrutinees, scrutineers and all those in the patient and public involvement system. The commissioning role is not an easy one to grasp for those on the receiving end of services. We will need to give particular attention to the seldom-heard voices of those patients and citizens who are most disempowered. For example, I look forward to the inclusion of patients in the development of the forthcoming commissioning guides by the National Institute for Health and Clinical Evidence.

More and more commissioning is carried out jointly or in some form of collaboration between the NHS and local government.

Underlying causes

Forthcoming legislation will carry on this impetus - and rightly, because of the significant role of local government in tackling the underlying causes of ill health and health inequalities. But this does mean that local government's role in health improvement and its partnership working with the NHS and others should also be held to account.

This should include the whole range of activities in which local government and other partners are engaged - schools, housing, transport and so on.

How do we enable constructive scrutiny of both local government and NHS commissioners, and promote shared accountability for partnerships? In seeking to take forward a recommendation from Sir David Carter's independent review of commissioning arrangements for specialised services, published in May 2006, can the Centre for Public Scrutiny-funded regional health scrutiny networks provide a focus for discussion?

Medical practices need to change with scientific advances. If I had a stroke today or I wanted angioplasty, I would want to go where there was round-the-clock expertise. That might mean going further away from home.

At the same time, we know that there is a lot of loyalty to local NHS institutions like district general hospitals, and a lot of suspicion from patients, the public and their elected representatives on scrutiny committees about proposed 'reconfigurations'.

Indeed, there is much treatment and care that is best done locally within communities. How can we assist scrutiny committees and patients' organisations to understand that not all changes in commissioning decisions are taken to resolve deficit problems, but may genuinely improve health; while respecting the great importance that service users give to local provision?

There is huge pressure on elected politicians to respond to the needs and views of their existing electorates.

What is much harder to do, and where I think the OSC has a role, is to talk with the future in mind, to take the perspectives and look to the interests of patients who have not yet been born.

Dr David Colin-Thome is national director for primary care.

Tim Gilling on public scrutiny

I see accountability's role in commissioning as being two-pronged: to ensure that commissioning supports real, informed patient choice while also ensuring it is tackling the health and care needs of whole communities. I suggest good scrutiny of commissioning strategies covers 10 areas:

  1. Context - the factors that influence poor health and their prevalence in the local area and among vulnerable communities.
  2. Levels of expenditure and investment - how these are decided and whether they are targeted in areas of greatest health need.
  3. Partnerships - whether there are any forms of partnership managing and delivering resources, which sectors are involved, which levels of care and how they are held accountable.
  4. Strategy - whether national policies such as the national service frameworks and NICE guidance are working in the local context; how national standards are operating locally, how this compares with other areas and lessons to be learnt.
  5. Leadership - who owns the commissioning process, who ensures delivery and whether those around the table are senior enough to effect change.
  6. Commissioning decisions - who takes the decisions; what information influences them; whether there is confidence they could commission services differently if necessary; what the opportunity costs are - what is not done as a result of commissioning decisions.
  7. Involvement - how the NHS is meeting its duty to involve and consult; whether there is evidence that involvement equals influence on commissioning decisions and the nature of service delivery. As someone said to me recently, turkeys are involved in Christmas, but they do not have much influence over the outcome of their participation.
  8. Access to services and pathways - whether people are clear about how to access services and what to expect from them; whether there are inequalities in access to services and what the commissioning strategy is doing to address them.
  9. Outcomes - how improved health outcomes from commissioning decisions are being measured.
  10. Change - how scrutineers can best exert influence that will bring about change and improvement in response to answers to the first nine areas of questioning. Getting good answers in these areas means closer involvement between commissioners, and others involved in local services - between GPs and ward councillors, for example, and between LINks and health scrutiny committees.

I support Dr David Colin-Thome's emphasis on education (above) and hope the Department of Health and also communities and local government recognise it too, as they will need to if there is to be real accountability and constructive 'place shaping' as described by Sir Michael Lyons in his local government review discussion documents.

Tim Gilling is manager of the Department of Health-funded health scrutiny support programme at the Centre for Public Scrutiny.